Automated diagnostic hearing test

ABSTRACT

Method and system are disclosed for automated testing of a patient&#39;s hearing. The automated hearing test allows the patient to quickly and accurately test his own hearing with minimal or no assistance from an audiologist or other hearing health professionals. The test prompts and instructs the patient for inputs and responses as needed. The patient can select one or several tests to be performed, including air and bone conduction testing with masking, speech reception threshold, speech discrimination, tympanogram, acoustic reflex, and otoacoustic emissions testing. Multiple languages are supported. Data obtained from one test may be used for another test or another iteration of the same test to calculate masking levels. The automatic hearing test also detects ambient noise and can compensate for it in the test results. If a contingency occurs, the automated hearing test is configured to page the operator for assistance.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a Divisional of U.S. patent application Ser. No.10/439,958, entitled “Automated Diagnostic Hearing Test,” filed May 15,2003, which claims the benefit of priority from, and hereby incorporatesby reference, U.S. Provisional Patent Application Ser. No. 60/383,303,entitled “Audiometer,” filed May 23, 2002, and U.S. Provisional PatentApplication No. 60/466,313, entitled “System and Method for ConductingMultiple Diagnostic Hearing Tests,” filed on Apr. 29, 2003.

STATEMENT REGARDING FEDERALLY SPONSORED RESEARCH

Not applicable.

REFERENCE TO APPENDIX

Not applicable.

BACKGROUND OF THE INVENTION

1. Field of the Invention

This invention is directed in general to the field of audiology and inparticular to an automated method and system for assessment and analysisof hearing loss.

2. Description of the Related Art

According to recent studies, over 20 million people in the United Statesalone have some degree of hearing loss. The number of people worldwidewho have some degree of hearing loss is estimated to be much greater.Not surprisingly, many of these people are unaware that they havesuffered a decrease in hearing capacity. The decreased hearing capacitymay be due to several factors, including age, health, occupation,injury, and disease. This loss of hearing can lead to significantreductions in quality of life, impaired relationships, reduced access toemployment and diminished productivity. Failure to treat the hearingloss may worsen the impact. According to the Better Hearing Institute,the annual cost in the United States in terms of lost productivity,special education, and medical care because of untreated hearing loss isapproximately $56 billion. Much of this staggering cost can be reducedor prevented by early detection and treatment. Unfortunately, few peopleobtain regular and frequent hearing tests as a part of their routinehealthcare due, in part, to the lack of a simple, convenient, andrelatively inexpensive hearing test.

Traditionally, a hearing test is conducted in a clinical setting by ahearing health professional, such as an audiologist, who administers thehearing test manually. The hearing health professional controls anaudiometer to produce a series of tones that each have a very specificfrequency and intensity. The term “intensity” as used herein refers tothe amplitude of the tone and is usually stated in decibels (dB). Thetones are then conducted through a transducer, such as earphones or earinserts, to the patient in a quiet room or sound isolation booth. Foreach audible tone, the patient gestures or otherwise indicates that hehas heard the tone. If the tone is not audible, the patient does notrespond. The hearing health professional thereafter adjusts theintensity level of the tone in preset increments until it becomesaudible to the patient. By repeating this process for several differenttones and compiling the results, the hearing health professional is ableto determine the extent of the hearing loss, if any.

An advantage of having a hearing health professional manually administerthe hearing test is the hearing health professional can apply hisconsiderable training and experience during the test. For example, bysimply talking to the patient and varying the loudness of his voice, thehearing health professional can determine an initial intensity level atwhich to start the tones and sounds. Furthermore, the hearing healthprofessional can adapt the pace of the test as needed to accommodate atired or uncooperative patient. More importantly, the hearing healthprofessional can discern between false responses or guesses andresponses that are legitimate. Finally, the hearing health professionalcan adjust the results of the hearing test as needed to reflectextenuating circumstances or problems, such as excessive ambient noise,equipment limitations, and other similar factors.

Like most highly trained and specialized medical professionals, however,a hearing health professional's time and services are usually veryexpensive. Accessibility and convenience can also be issues, as thereare fewer hearing health professionals relative to other types ofmedical professionals. And while hearing health professionals are highlytrained, they are limited in their ability to make rapid and accuratecalculations of the test data and have to rely on approximations andrules of thumb for guidance in many instances. In addition, few hearinghealth professionals in the United States can speak a foreign language.As a result, traditional hearing tests are almost always administered inEnglish, which can be a problem for non-English speaking patients.

Other drawbacks of the traditional, manually administered hearing testsinclude the need for a quiet room or sound isolation booth in order toproperly conduct the tests. The quiet room or sound isolation booth hasto comply with ANSI (American National Standards Institute) requirementsin terms of how much noise may penetrate the room or booth during atest. Typically, a specially trained technician must evaluate andcertify the quiet room or sound isolation booth as meeting ANSIstandards before the room or booth can be used. At present, there arerelatively few technicians who are trained to perform such evaluationsand certifications. All the above factors combine to increase thecomplexity of the traditional hearing tests and thereby discourage or atleast contribute to a general lack of interest by most people inobtaining regular and frequent hearing tests.

One attempt to simplify the traditional hearing test involves the use ofa computer network, such as the Internet, to administer the test. Thecomputer network facilitates interaction between a centralized testadministration site and remotely located patient sites. Such anarrangement makes it possible (or at least more convenient) for peoplein remote or rural areas to obtain a hearing test. And the hearing testcan be performed so that it meets standardized guidelines such as ANSIrequirements or certification standards. Despite the increasedconvenience, a hearing health professional must still manuallyadminister the test, albeit remotely. In this regard, the test is verysimilar to the traditional hearing test and has many of the sameshortcomings.

Accordingly, what is needed is a hearing test that overcomes theshortcomings of the traditional hearing test. Specifically, what isneeded is a hearing test that is simpler, more convenient, lessexpensive, can be administered by the patient rather than by the hearinghealth professional, yet does not compromise the accuracy orthoroughness of the traditional, manually administered hearing test.

SUMMARY OF THE INVENTION

The present invention is directed to a method and system for automatedtesting of a patient's hearing. The automated hearing test allows thepatient to quickly and accurately test his own hearing with minimal orno assistance from an audiologist or other hearing health professionals.The test prompts and instructs the patient for inputs and responses asneeded. The patient can select one or several tests to be performed,including air and bone conduction testing with masking, speech receptionthreshold, speech discrimination, and tympanogram/acoustic reflextesting. Multiple languages are supported. Data obtained from one testmay be used for another test or another iteration of the same test tocalculate masking levels. The automatic hearing test also detectsambient noise and can compensate for it in the test results. If acontingency occurs, the automated hearing test is configured to page theoperator for assistance.

BRIEF DESCRIPTION OF THE DRAWINGS

A better understanding of the invention may be had by reference to thefollowing detailed description when taken in conjunction with theaccompanying drawings, wherein:

FIG. 1 illustrates an exemplary system for providing an automatedhearing test according to embodiments of the invention;

FIG. 2 illustrates a block diagram of the system for providing anautomated hearing test according to embodiments of the invention;

FIG. 3 illustrates the exemplary functional components of the automatedhearing test according to embodiments of the invention;

FIG. 4 illustrates an exemplary flowchart for a main program moduleaccording to embodiments of the invention;

FIG. 5 illustrates an exemplary flowchart for a pure tone frequencymodule according to embodiments of the invention;

FIG. 6 illustrates an exemplary flowchart for a pure tone thresholdmodule according to embodiments of the invention;

FIG. 7 illustrates an exemplary flowchart for a pure tone intensitymodule according to embodiments of the invention;

FIG. 8 illustrates an exemplary flowchart for a pure tone initialintensity module according to embodiments of the invention;

FIG. 9 illustrates an exemplary flowchart for a set pure tone maskinglevels module according to embodiments of the invention;

FIG. 10 illustrates an exemplary flowchart for a threshold detectionmodule according to embodiments of the invention;

FIG. 11 illustrates an exemplary flowchart for a speech receptionthreshold module according to embodiments of the invention;

FIG. 12 illustrates an exemplary flowchart for a set speech maskinglevels module according to embodiments of the invention;

FIG. 13 illustrates an exemplary flowchart for a speech discriminationmodule according to embodiments of the invention; and

FIG. 14 illustrates an exemplary flowchart for a patient managementmodule according to embodiments of the invention.

DETAILED DESCRIPTION OF THE INVENTION

Following is a detailed description of the invention with reference tothe drawings wherein reference numerals for the same or similar elementsare carried forward.

As mentioned above, the present invention is directed to a method andsystem for automated testing of a patient's hearing. The term “automatedtesting” as used herein refers to testing that is performed primarily bya computer, as opposed to testing that is performed primarily by ahearing health professional. The automated hearing test allows thepatient to test his own hearing with minimal or no assistance from anaudiologist or other hearing health professional. Typically, anoperator, such as the hearing health professional or a trainedassistant, helps the patient with the initial set up (e.g., seating,putting on the headset, demonstrating button usage, etc.) and explainshow the test works. Thereafter, the automated hearing test prompts andinstructs the patient for all inputs and responses needed. If acontingency occurs, for example, the patient falls asleep, the automatedhearing test alerts (e.g., by paging) the operator as needed. Such apatient-administered hearing test can be simpler, more convenient, andless expensive than the traditional, audiologist-administered test.

In addition, the hearing test of the present invention provides anaccurate and thorough assessment of the patient's hearing. The automatedhearing test includes air and bone conduction testing with masking,speech reception threshold testing, speech discrimination testing, andcan accommodate tympanogram, acoustic reflex, otoacoustic emission, andacoustic immitance testing. The tests are performed in a manner tocomply with relevant standards and guidelines such as ANSI requirementsand other standards. Furthermore, the automated hearing test can detectand compensate for ambient noise and, therefore, does not require theuse of a certified quiet room or sound isolation booth. Finally, theautomated hearing test can be configured for any number of languages forpatients in all parts of the world.

Hearing health professionals will also benefit from the automatedhearing test of the present invention. Although the test itself requireslittle or no intervention, a hearing health professional still mustanalyze the test results and recommend treatment. Therefore, theautomated hearing test is, at least initially, made available onlythrough a qualified hearing health professional. The hearing healthprofessional may offer the automated hearing test as a separate serviceor as part of a more comprehensive service, such as a full physicalcheckup that patients can obtain annually. Since the test requireslittle or no intervention, the hearing health professional does not haveto spend much time administering the test. As a result, he will havemore time for each patient and/or be able to treat more patients.Moreover, since the automated hearing test facilitates early detectionof hearing loss, the treatment needed may be less severe than if thehearing loss had been detected later.

Referring now to FIG. 1, a system 100 for providing automated hearingtests according to some embodiments of the invention is shown. Thesystem 100 has three main components, namely, a computer 102, and adisplay screen 104, and at least one transducer 106. Other components ofthe system 100 that may be present include a tympanometer, keyboard,mouse, printer, paging system, and the like (indicated generally at108). The paging system may be any suitable paging technology that usesone or more pagers or other wireless mobile devices 108 for alerting theoperator. The mobile terminal 108 preferably can display text messagesfor informing the operator of the nature of the alert. Other types ofpaging system may also be used without departing from the scope of theinvention (e.g., wired paging systems).

The computer 102 may be any suitable computer, from a desktop PC to ahigh-end workstation, as the particular type/model/brand of computer isnot overly important to the practice of the invention. The displayscreen 104 may likewise be any suitable display screen, from a CRT to anLCD, as the particular type/model/brand of display screen is not overlysignificant for purposes of the present invention. In some embodiments,however, a touchscreen monitor may be easier to use than conventionalCRT for LCD display screens in terms of the physical interaction betweenthe patient and the automated hearing test.

As for the transducer 106, this component may be an ear insert,earphones, and the like for air conduction. For bone conduction, thetransducer 106 may be a vibrator or other similar devices. In somecases, the transducer 106 may be mounted on a headset worn by thepatient. Usually, a separate transducer is used for air conductionversus bone conduction and the transducers are swapped as need duringthe hearing test. Preferably, the bone conduction transducer is arrangedin such a way as to allow testing of either ear without moving thetransducer and without interfering with the air conduction transducer.In some embodiments, both the air conduction transducer and the boneconduction transducer are combined in a single unit. An example of sucha combined unit is described in U.S. Provisional Patent Applicationentitled “System and Method for Conducting Multiple Diagnostic HearingTests,” filed on Apr. 29, 2003, which is incorporated herein byreference.

FIG. 2 illustrates the system 100 in block diagram form. As can be seen,the computer 102 has a number of functional components, including avideo unit 200, a central processing unit 202, a hearing test device204, and a storage unit 206. These components are well known in thecomputer art and will therefore be described only briefly here. Ingeneral, the video unit 200 provides the video signals that aredisplayed as images on the display screen 104. In some embodiments, thevideo unit 200 may be any one of several commercially available videocards. The central processing unit 202 is responsible for the overalloperation of the computer 102, including execution of the operatingsystem and any software applications residing on the computer 102. Insome embodiments, the central processing unit 202 may be any one ofseveral commercially available microprocessors. The hearing test device204 may comprise any or all of an audiometer, an otoacoustic emissiontest device, a tympanometer, a masking noise generator, or other hearingtest devices. In some embodiments, the hearing test device 204 may beone or more electronic circuit boards within the computer 102 forperforming the functionality of such test devices. Alternatively, thehearing test device 204 may be a separate unit that is external to thecomputer 102. The storage unit 206 provides long-term and temporary(i.e., caching) storage for the software and data that are used by thecomputer 102 and may include one or more of, for example, a hard drive,main memory, removable storage (e.g., CD-ROM, floppy disk), and thelike.

In some embodiments, the storage unit 206 also stores the automatedhearing test of the present invention, indicated at 208. Morespecifically, the storage unit 206 stores a computer-readable version ofthe automated hearing test 208 that can be executed by the computer 102.During execution, a portion of the automated hearing test 208 may betemporarily loaded from, for example, the hard disk and into the mainmemory components of the storage unit 206. In addition to thestand-alone arrangement, it is also possible to execute the automatedhearing test 208 from a network. For example, the automated hearing test208 may be stored on a server computer (not expressly shown) that isaccessible to several client computers. This arrangement has anadvantage in that updates to the automated hearing test 208 may bequickly and easily implemented. Other environments for executing theautomated hearing test 208 may also be used without departing from thescope of the invention.

The source code for the automated hearing test 208 may be written in anysuitable programming language (e.g., C, C++, BASIC, Java). It has beenfound, however, that object oriented programming languages such as C++,Visual Basic and Java can result in a somewhat more efficient program.In addition, the automated hearing test 208 can be implemented using anumber of different programming methodology (e.g., top-down, objectoriented). The particular programming methodology as well as theparticular programming language used are not overly importantconsiderations for the practice of the invention. In one embodiment, themethodology of the automated hearing test 208 involves a plurality ofindividual modules or object class modules with subroutines, propertiesand functions that can be called to perform specific tasks. The modulesor subroutines can be called from a main routine and from within othermodules or subroutines. The subroutines can pass data to and from eachother as well as to and from the main routine. FIG. 3 shows an exampleof this particular embodiment of the automated hearing test 208.

As can be seen in FIG. 3, the automated hearing test 208 includes a mainprogram module 300 and a plurality of individual subroutines or classmodules, including a pure tone frequency module 302, and a pure tonethreshold module 304. A pure tone intensity module 306, a pure toneinitial intensity determination module 308, and a pure tone maskinglevels module 310 are also present. Other modules include a thresholddetection module 312, a speech reception threshold module 314, a speechmasking levels module 316, a speech discrimination module 318, and apatent management module 320. In evaluating the various modules, itshould be emphasized that this particular combination of modules isexemplary only, and that one or more modules may be omitted or othermodules may be added as needed. Furthermore, two or more modules may becombined into a single module, or a single module divided into severalsub-modules as needed.

Functionally, the main program module controls the general sequence orflow of the hearing test 208. When specific functions or tasks need tobe performed, the main program module calls the appropriate modules toperform the needed functions or tasks. For example, the main programmodule calls the pure tone frequency module in order to test thepatient's ability to hear pure tone frequencies. Similarly, the speechreception threshold module is called in order to test the patient'sability to hear speech, and the speech discrimination module is calledin order to test the patient's ability to discriminate between similarsounding words.

Each of the modules can also call other modules when specific functionsor tasks need to be performed. For example, while the pure tonefrequency module controls which pure tone frequencies will be tested andin what sequence, the actual threshold testing is performed by one orseveral other modules. Thus, after being called by the main programmodule, the pure tone frequency module can call, for example, the puretone intensity module in order to obtain the patient's thresholdintensity for a given frequency. The pure tone intensity module, inturn, calls the pure tone initial intensity determination module inorder to determine the initial intensity level at which to begintesting. The pure tone intensity module also calls the pure tone maskinglevels module in order to determine the amount of masking that should beused with a given frequency. Finally, the pure tone intensity modulecalls the threshold detection module in order to establish whether athreshold intensity has been reached. The threshold detection module canalso be called by the speech reception threshold module for the samepurpose. The speech reception threshold module further calls the speechmasking levels module in order to determine the amount of masking to beused during the speech reception threshold test. FIGS. 4-13 illustrateone exemplary implementation out of several possible implementations foreach of the modules 302-320.

A key design feature of the automated hearing test is the ability toshare data between all the modules that are called. For example, dataacquired by the pure tone frequency module during the pure tonefrequency test may be shared with the speech reception threshold moduleduring the speech reception threshold test. Similarly, data acquiredduring one iteration of a module may be shared with another iteration ofthe same module. This type of data sharing arrangement results in a moreefficient and more accurate test overall. Where no data exists to beshared, the modules may use rules of thumb type data or best-guest typedata.

Referring now to FIG. 4, a flowchart 400 illustrates the operation ofthe main program module according to some embodiments of the invention.As mentioned above, the main program module controls the generalsequence or flow of the automated hearing test 208. The main programmodule allows the patient to select which tests are to be performed,then controls when and how various subroutines or modules are called tocarry out the selected tests. After initial power up, the main programmodule performs an equipment check at step 401 to ensure all components(e.g., transducers, audiometer, etc.) of the system are functioningproperly. Such a check may involve, for example, comparing the initialcalibration data of the equipment with current measurements. In someembodiments, the various components of the equipment may bepre-calibrated together as a unit during manufacture or assembly. Thecalibration data may then be stored in a storage medium that isconnected or attached to or sent together with the equipment. Adetermination is made at step 402 as to whether the equipment checkpassed, that is, whether the equipment is within a predeterminedpercentage of the initial calibration data. If the equipment checkfails, then the main program module issues an equipment failure warningat step 403 and returns to the first step 401 to re-check the equipment.

If the equipment check passes, then the main program module proceeds toobtain the patient's information at step 404. This can be done, forexample, by prompting the patient to manually enter his information(e.g., name, address, date of birth, etc.), or by loading theinformation from a previously stored patient file. Here, as throughoutthe description, manual prompting may be done visually by displaying theinstructions as text on the display screen 104, or by audio instructionsvia the transducer 106, or by a combination of both in a multimediaapproach. At step 405, the main program module obtains the patient'spreferred language (e.g., English, Spanish, French, etc.), again, byprompting the patient, or by loading the selection from a previouslystored file. At step 406, the main program module allows the patient toselect one of several tests to be performed, including atympanogram/acoustic reflex test, a pure tone test, a speech receptionthreshold test, and a speech discrimination test.

After the above selection, the main program module makes a determinationas to whether the tympanogram/acoustic reflex test was selected at step407. The purpose of this test is to check the acoustic admittance of theear and is usually conducted by an operator of a tympanometer (indicatedgenerally at 108). The tympanometer may be any suitable tympanometerthat can be connected to and communicate with the computer 102. Mostcommercially available tympanometers have a serial, parallel, or otherdata port that can be used to transfer data to and from the computer102. If the tympanogram/acoustic reflex test was selected, then at step408, the main program module presents the operator with the left earinstructions (e.g., insert tympanometer, start test). At step 409, themain program module obtains the left ear data from the tympanometer. Themain program module thereafter prompts the operator at step 410 toindicate whether the data is acceptable. If the operator indicates thedata is not acceptable, the main program module asks the operator atstep 411 whether to keep trying to obtain a tympanogram for the leftear. If the operator decides to keep trying, then the main programmodule repeats the process for the left ear starting at step 408. On theother hand, if the operator decides not to keep trying, or that the datais acceptable, then the main program module runs through the sameprocess for the right ear at steps 412, 413, 414, and 415.

In some embodiments, instead of the operator performing thetympanogram/acoustic reflex test, the automated hearing test 208 maycontrol the tympanometer so that the test is performed automatically. Inthese embodiments, the tympanometer may be a separate unit, or it may bea part of the functionality provided by the hearing test device 204. Themain program module may then be configured to provide instructions tothe patient on how to insert the probes for the tympanogram/acousticreflex test. The probes may be standard probes used for such tests, orthey be combination probes similar to the one described in U.S.Provisional Patent Application entitled “System and Method forConducting Multiple Diagnostic Hearing Tests,” mentioned above. The mainprogram module then controls the operation of the tympanometer toinitiate the test and acquires the resulting data. A similar arrangementmay be used for other hearing related tests.

If the tympanogram/acoustic reflex test was not selected step 407, thenthe main program module proceeds to step 416, where it checks whetherthe pure tone test was selected. The purpose of this test is to assesswhat loss has occurred in the patient's ability to hear pure tones(e.g., a single frequency or a very narrow band of frequencies). Thedata obtained during the pure tone frequency test can then be used forthe other tests. If the pure tone test was not selected, the programmodule proceeds to step 419. If the pure tone test was selected, themain program module thereafter presents instructions to the patient atstep 417 on how to perform the test (e.g., what to expect, when torespond, how to respond, etc.). At step 418, the main program modulecalls the pure tone frequency module to perform the pure tone test, thedetails of which will be described below. The main program modulethereafter proceeds to step 419 for the speech reception threshold test.

At step 419, a determination is made as to whether the speech receptionthreshold tests was selected. The purpose of this test is to assess whatloss has occurred in the patient's ability to hear speech. If the speechreception threshold test was not selected, then the main program moduleproceeds directly to step 422 for the speech discrimination test. If thespeech reception threshold test was selected, then the main programmodule presents instructions to the patient on how to perform the testat step 420 (e.g., what to expect, when to respond, how to respond,etc.). The main program module thereafter calls the speech receptionthreshold module to perform the speech reception threshold tests at step421, the details of which will be described below. The main programmodule then proceeds to step 422 for the speech discrimination test.

At step 422, a determination is made as to whether the speechdiscrimination test was selected. The purpose of this test is to assesswhat loss has occurred in the patient's ability to discriminate betweensimilar sounding words. If the speech discrimination test was notselected, then the main program module proceeds directly to step 425 toconclude the test session. Otherwise, the main program module presentsinstructions to the patient on how to perform the test at step 423(e.g., what to expect, when to respond, how to respond, etc.). The mainprogram module thereafter performs the speech discrimination tests atstep 424, the details of which, again, will be described with respect toFIG. 4 below. The main program module then proceeds to step 425 toconclude the test session.

At step 425, the main program module alerts the operator that thepatient has completed his hearing test, for example, by causing theoperator to be paged. In some embodiments, the main program module alsopages the operator if the patient does not complete the hearing testwithin a reasonable amount of time, for example, one hour. If thepatient has not completed the hearing test within the given time, thenthat may indicate the patient is having some difficulty progressingthrough the test. The operator may also be paged by the patient, forexample, by pressing an onscreen button if he needs assistance. Oncecompleted, the main program module saves the data acquired from thetest, for example, by storing the data onto a disk of the storage unit206 at step 426. At step 427, the main program module generates andprints a standardized report based on the test data from the justconcluded test session.

At step 428, the main program module offers the operator a number ofoptions, including the option to view the results, repeat the test,begin a new session, print the test data, and archive the results. Themain program module thereafter waits for the operator to make aselection. If the operator chooses to view the results, the main programmodule displays the test data on the display screen 104, and returns tothe previous step. If the operator chooses to rerun the hearing test,the main program module returns to step 406 and prompts the operator toselect the tests to be rerun. If, on the other hand, the operatorchooses to begin a brand new session, the main program module returns tothe very first step 401. If the operator chooses to print the testresults, then the main program module returns to step 427 and prints theresults. If the operator chooses to archive the results, then the mainprogram module returns to step 426 and saves the result to disk.

Referring now to FIG. 5, a flowchart 500 illustrates an exemplaryimplementation of the pure tone frequency module according toembodiments of the invention. The pure tone frequency module controlswhich pure tone frequencies are tested and in which sequence. As will bedescribed below, a key design feature of the pure tone frequency moduleis its ability to determine whether certain frequencies need to betested and to bypass the ones that do not need testing. This type offrequency selection process is very similar to the process that ahearing health professional would go through during a manuallyadministered test and can result in a shorter and more efficient testoverall.

At the first step 501, the pure tone frequency module obtains thethreshold intensity for the first pure tone, which is about 1000 Hz inthis embodiment. The threshold intensity is defined as the lowestintensity, rounded to the nearest 5 dB, at which the tone is audible tothe patient at least 50% of the time. The pure tone frequency moduleobtains the threshold intensity by calling the pure tone thresholdmodule and passing to it the frequency to be tested. The pure tonethreshold module performs the pure tone threshold test (described below)and returns the results to the pure tone frequency module. At the secondstep 502, the pure tone frequency module obtains the threshold intensityfor the second pure tone, which is about 500 Hz in this embodiment, byagain calling the pure tone threshold module and passing the second puretone information to it.

At the next step 503, the pure tone frequency module determines whetherit needs to test below the 500 Hz level. This step is an optional stepthat is intended to reduce test time by skipping the lower frequenciesif the results of lower frequency testing would not significantly add tothe diagnostic information included in the hearing test report. The puretone frequency module makes the determination by comparing the patient'sthreshold intensity at 500 Hz to the minimum significant 500 Hzthreshold. The minimum significant 500 Hz threshold, according to someaudiologists, is between 10 dB and 30 dB. If the patient's thresholdintensity at 500 Hz is greater than or equal to the minimum significant500 Hz threshold, then the pure tone frequency module proceeds to obtainthe threshold intensity at a lower frequency, which is about 250 Hz inthis embodiment, at step 504. If the patient's 500 Hz thresholdintensity is less than the minimum significant 500 Hz threshold, thenthere is less of a need to test at lower frequencies and time can besaved by skipping these frequencies. This demonstrates the advantage ofstarting the pure tone test at 1000 Hz rather than at the lowestfrequency in the audible spectrum, since it is not always necessary totests at the lowest frequencies. In some embodiments, however, the puretone frequency module may test the lower frequencies anyway, or it maystart at the lowest frequency in order to be as thorough as possible.

Next, the pure tone frequency module proceeds to obtain the thresholdintensity at, for example, 2000 Hz (step 505) and at 4000 Hz (step 506),by again calling the pure tone threshold module and passing thefrequency information to it. The pure tone frequency module maythereafter implement another optional time-saving measure at step 507 bydetermining whether the difference between the 2000 Hz and 4000 Hzthresholds is greater than a minimum significant interoctave difference.This minimum significant interoctave difference is considered by someaudiologist to be about 20 dB. If the difference between the 2000 Hz and4000 Hz thresholds is greater than or equal to the minimum significantinteroctave difference, then the pure tone frequency module proceeds atstep 508 to obtain the threshold intensity at 3000 Hz. Otherwise, thepure tone frequency module proceeds to step 509 to obtain the thresholdintensity at, for example, 8000 Hz. At this point, the pure tonefrequency module may implement another optional time-saving measure atstep 510 by determining whether the difference between the 4000 Hz and8000 Hz thresholds is greater than or equal to the minimum significantinteroctave difference. If it is, then the pure tone frequency moduleproceeds at step 511 to obtain the threshold intensity at anintermediate frequency, for example, 3000 Hz. Otherwise, the pure tonefrequency module concludes the procedure and returns the results to themain program module.

While the exemplary implementation of the pure tone frequency moduledescribed above started the pure tone testing at 1000 Hz, a personhaving ordinary skill in the art will recognize that other startingpoints may be used without departing from the scope of the invention.For example, the pure tone frequency module could start the testing at8000 Hz and work down to the lower frequencies to obtain essentiallysimilar results. Also, the pure tone frequency module may testfrequencies above 8000 Hz, below 250 Hz, or at other interoctavefrequencies not mentioned above without departing from the scope of theinvention.

Turning now to FIG. 6, a flowchart 600 illustrates an exemplaryimplementation of the pure tone threshold module according to someembodiments of the invention. The pure tone threshold has theresponsibility of coordinating the various tasks required to determine athreshold intensity for each pure tone frequency tested. For each puretone frequency, the pure tone threshold module first obtains an unmaskedbone threshold at step 601 by calling the pure tone intensity module(described below). The pure tone threshold module thereafter uses theunmasked bone threshold to determine whether the left ear or the rightear is louder, provided this determination has not already been made ina previous iteration. If it turns out that the louder ear determinationhas already been made, then the pure tone threshold module can skip thisdetermination in the current iteration.

Thus, at step 602, the pure tone threshold module determines whether theunmasked bone threshold just obtained is the first unmasked bonethreshold. If it is not, then that means the louder ear determinationhas already been made in a previous iteration, and the pure tonethreshold module may proceed directly to the better ear air thresholdtest at step 607. If the unmasked bone threshold just obtained is thefirst unmasked bone threshold, then at step 603, the pure tone thresholdmodule presents the frequency being tested to the patient using anintensity level roughly equal to the unmasked bone threshold plus amargin (e.g., 10 dB). The patient is then prompted at step 604 toindicate which ear can hear the frequency louder. Based on the patient'sresponse, either the left ear is marked as the better one (step 605) orthe right ear is marked as the better one (step 606). Note that thisstep is an optimization step and, if omitted, might make the test alittle longer, but would not alter the end results.

At step 607, for whichever ear was denoted as the better ear, the puretone threshold module obtains an air threshold for that ear by againcalling the pure tone intensity module. The pure tone intensity moduleobtains an air threshold for the ear being tested and returns theresults to the pure tone threshold module. The pure tone thresholdmodule thereafter determines at step 608 whether the frequency beingtested is the first frequency, which is 1000 Hz in this embodiment. Ifit is not, the pure tone threshold module proceeds to step 611 to obtainthe air threshold for the other, poorer ear. On the other hand, if thefrequency being tested is the first frequency, then at step 609, thepure tone threshold module determines whether the unmasked bonethreshold is more than 20 dB worse than the air threshold just obtained.If it is not, the pure tone threshold module again proceeds to step 611.If the unmasked bone threshold is more than 20 dB worse than the airthreshold just obtained, the pure tone threshold module raises asuspicious bone threshold warning at step 610. In some embodiments, thepure tone threshold module also alerts the operator, as this is usuallyan indication that the bone conduction transducer is disconnected, noton the patient, or has otherwise failed. The pure tone threshold modulethereafter proceeds to step 611.

At step 611, the pure tone threshold module again calls the pure toneintensity module to obtain the air threshold for the poorer ear. At step612, the pure tone threshold module determines whether the air-bone gapfor either ear is greater than or equal to a minimum significantair-bone gap, which might indicate that a masked bone threshold isneeded to establish the bone conduction of each ear. The minimumsignificant air-bone gap is about 10 dB according to some audiologists.Most people with normal hearing will have an air-bone gap that issmaller than this and, therefore, a masked bone threshold will not beneeded and the pure tone threshold module can proceed directly to step616.

If, however, the air-bone gap for either ear is greater than or equal tothe minimum significant air-bone gap, then the pure tone thresholdmodule proceeds to obtain masked bone thresholds, beginning with thepoorer ear at step 613 (by calling the pure tone intensity module). Thepure tone threshold module thereafter determines whether the masked boneand unmasked bone difference for that ear is less than or equal to amaximum central masking effect. The central masking effect is a measureof the level of masking noise introduced at the contralateral ear thatcan influence the audibility of tones at the ipsilateral ear. Themaximum central masking effect is considered by some audiologist to beabout 20 dB. If the poorer ear masked bone threshold is worse than theunmasked bone threshold by more than the central masking affect, one cansafely assume that the unmasked bone threshold pertains to the betterear, and a separate threshold is not necessary. If, however, the poorerear masked bone versus unmasked bone difference is less than or equal tothe maximum central masking effect, then the pure tone threshold moduleproceeds to obtain the better ear masked bone threshold at step 615.

Note that steps 612 and 614 are optional time saving measures, since inmost people with normal hearing, the pure tone threshold module willproceed directly to step 616 from these steps. At step 616, the puretone threshold module reevaluates the masking levels used for eachthreshold obtained at steps 607, 611, 613, and 615 (if available) basedon the most recent threshold information for the frequency being tested.It is possible that an early masked threshold was obtained withinsufficient masking, since any conductive loss that may be present inthe masked (non-test) ear would not be known ahead of time. For thisreason, the masking level used for all thresholds at the frequency beingtested are reevaluated after each new threshold is obtained in orderensure use of the most recent threshold information in determiningappropriate masking levels. Reevaluation involves calculating theminimum masking level (described in more detail with respect to FIG. 9)using the most recent thresholds for the frequency being tested. If thenewly calculated minimum masking level and the level used to obtain thethreshold are different by more than a predetermined amount, then thethreshold that was obtained may not be correct.

At step 617, the pure tone threshold module determines whether allmasked thresholds have been correctly masked from the results of step616. If they have, the pure tone threshold module concludes itsprocedure for the frequency being tested and returns the results to thepure tone frequency module. Otherwise, the pure tone threshold moduledetermines whether the better ear air masking (step 618) and poorer earair masking (step 619) were correct. If the air masking for either earwas incorrect, the pure tone threshold module repeats the air thresholdprocedure for the affected ear. The pure tone threshold modulethereafter determines whether the bone threshold exists and bone maskingwas correct for the poorer ear (step 620) and the better ear (step 621).If the determination is no for either ear, the pure tone thresholdmodule repeats the unmasked bone threshold procedure for the affectedear. The pure tone threshold module thereafter returns to step 617 todetermine once again whether all mask thresholds were correctly maskedfor the frequency being tested. This process is repeated until allnecessary thresholds are obtained with the proper masking levels.

FIG. 7 illustrates a flow chart 700 of an exemplary implementation ofthe pure tone intensity module according to some embodiments of theinvention. As mentioned above, the pure tone intensity module is calledby the pure tone threshold module in order to determine an individualthreshold intensity for the pure tone frequency being tested. The puretone intensity module presents the frequency being tested using a seriesof different intensity levels and checking each level to see if it is atthe patient's hearing threshold for that frequency. For each frequency,the pure tone intensity module begins by first determining the intensitylevel that should be used to start the testing. The pure tone intensitymodule then sets the masking level for that intensity level, and foreach subsequent intensity level as needed.

One key design feature of the pure tone intensity module is thedetection of a false response. If the intensity level testing reachesthe equipment lower limit and still no threshold has been found, thenthe patient may be guessing or trying to anticipate the tones. In someembodiments, the pure tone intensity module turns the intensity leveloff at this point and checks whether the patient heard a tone. If hedid, then the patient is given a false response warning, since he couldnot have heard a tone with the intensity turned off.

Another key design feature of the pure tone intensity module is that itmeasures the level of ambient noise present during an ongoing test. Thisallows the automated hearing test of the present invention to compensatefor the ambient noise. As a result, the automated hearing test can beperformed without a quiet room or a sound isolation chamber. The ambientnoise may be measured at regular intervals, or at various predeterminedpoints throughout the test. In some embodiments, the ambient noise maybe measured at the moment each intensity level is used. In this way,real time analysis of the ambient noise is performed for each intensitylevel and can be compensated for as needed.

To determine the starting intensity level, the pure tone intensitymodule calls the pure tone initial intensity determination module(described below) at step 701. It also calls the set pure tone maskinglevels module at step 702 to determine the amount of masking for thatintensity level. At step 703, the pure tone intensity module determineswhether there is a problem with the masking level returned by the setpure tone masking levels module. A masking problem may result fromequipment limitations (i.e., the masking level is beyond the limitationsof the audiometer or the transducer), or the problem may be due to amasking dilemma. A masking dilemma occurs when the minimum masking levelrequired at the non-test ear also masks the test ear due to crossover,causing the threshold levels in the test ear to be shifted. When suchmasking problems occur, the pure tone intensity module simply concludesits procedure for the frequency being tested and returns to the puretone threshold module. In some embodiments, however, the pure toneintensity module may proceed anyway with unmasked thresholds in the caseof a masking dilemma.

If there is no masking problem, then the pure tone intensity moduleproceeds with the testing by starting the ambient noise measurement atstep 704. The ambient noise may be measured using any microphonessuitable for the task, such as those described in U.S. ProvisionalPatent Application entitled “System and Method for Conducting MultipleDiagnostic Hearing Tests” mentioned above. Preferably, one microphone isplaced near each ear, but it is also possible to place the microphonesat other locations. At step 705, the pure tone intensity moduledetermines whether the current masking level is different from theprevious iteration's masking level. This determination is importantbecause a change in the masking level can sometimes clue the patientthat a tone is about to be presented. If there has been a change in themasking level, then the pure tone intensity module introduces a randomdelay (e.g., 0.5 to 3 seconds) at step 706 before presenting the tone.On the other hand, if the masking level did not change, but the patientresponded to a prior stimulus at step 707 (which could happen only onthe second and subsequent iterations of this loop), the pure toneintensity module will still introduce a random delay before presentingthe tone. If the patient did not respond to a prior stimulus, however,then the pure tone intensity module proceeds with presentation of thetone pulse train at step 708. The presentation of the tone pulse trainlasts about two seconds in some embodiments, but may be adjusted longeror shorter as needed. In some embodiments, a non-pulsed tone orfrequency modulated tone (warble) may be used in place of a pulsed tone.

At step 709, the pure tone intensity module concludes the ambient noisemeasurement. This measurement will then be used to compensate for thelevel of ambient noise if needed. The pure tone intensity modulethereafter determines at step 710 whether the patient responded prior tothe start of the tone presentation. Such a response may indicate thepatient is guessing or trying to anticipate the presentation of thetone. When this happens, the pure tone intensity module increments afalse response counter at step 711, and determines whether the currentmasking is the first time masking is used for the frequency under testat step 712. If it is, then the false response may have been due to thepatient not being ready for the sudden introduction of the maskingnoise. At this point, the pure tone intensity module internally raises afalse response warning at step 713 to the patient, and returns to theset pure tone masking levels step 702 so that the same tone presentationcan be repeated.

If the current masking is not the first time masking is used for thefrequency under test (step 712), then the pure tone intensity moduledetermines at step 714 whether the false response counter in step 711has exceeded a predetermined limit. The predetermined limit isarbitrarily set at three false responses in some embodiments, but may beadjusted higher or lower as needed. If the false response counter hasexceeded the predetermined limit, the pure tone intensity module raisesa false response warning at step 715, which can be used to alert theuser to respond only when they hear a tone. The pure tone intensitymodule thereafter resets the intensity level for the tone to the initialvalue at step 716, and returns to step 702 to begin the procedure again.

If the false response counter has not exceeded the predetermined limit,then the pure tone intensity module continues at step 717, where itdetermines whether the patient responded before expiration of a postpresentation timeout period. The post presentation timeout period allowssome time for the patient to respond even after the tone pulse train hasstopped. This timeout period may be in the 0 to 2 second range; in thisembodiment, the time period is set to about 0.5 seconds If the patientdoes respond before the post presentation timeout period expires, thenthe pure tone intensity module determines at step 718 whether thatresponse occurred while the intensity level of the tone was off. Theintensity level is turned off if the lower limit of the equipment hasbeen reached and still no threshold has been found. This means thepatient is probably trying to guess of anticipate the tones, as he couldnot have heard any tone while the intensity was turned off. The puretone intensity module thereafter proceeds to issue the false responsewarning at step 715.

On the other hand, if the intensity level was not off, then the puretone intensity module checks at step 719 to see if a threshold has beenreached. The pure tone intensity module performs his task by calling thethreshold detection module (described below). Afterwards, adetermination is made at step 720 as to whether a threshold for thefrequency being tested was found. If a threshold was found, the puretone intensity module concludes its procedure for this frequency andreturns the results to the pure tone threshold module. If a thresholdwas not found, then at step 721, the pure tone intensity moduledetermines whether the current intensity level has reached theequipment's lower limit. If it has, then at step 722, the pure toneintensity module turns the intensity level off and returns to step 702where the procedure will be repeated with no tone. If the currentintensity level is not at the equipment's lower limit, then the puretone intensity module decreases the intensity level at step 723 by apredetermined increment and returns to step 702 to repeat the procedurewith the new intensity level.

Referring back to step 717, if the patient did not respond beforeexpiration of the post presentation timeout period, meaning there was nopatient response to the tone presentation, then the pure tone intensitymodule determines at step 724 whether the current intensity level hasreached the equipment's upper limit. If it has, then the pure toneintensity module records that the patient's threshold intensity for thefrequency being tested is above the equipment limit at step 725, andraises an internal warning at step 726. In some embodiments, the patientmay be asked to press an on-screen button at this point to indicate thatthey have not dozed off during the test. If the button is pressed in atimely manner, then the test can continue; if not, the operator may bepaged to wake the patient and help him get back to the task ofresponding to tones.

If the current intensity is not at the equipment's upper limit, then atstep 727, the pure tone intensity module checks the level of ambientnoise present. In some embodiments, the pure tone intensity moduleperforms this check by determining whether the ambient noise thresholdshift is greater than or equal to the current intensity level. Anambient noise threshold shift occurs when the ambient noise level isgreater than the minimum level allowed by ANSI standards. The shift canbe determined, as known to persons having ordinary skill in the art, byperforming a frequency analysis of the ambient noise (measured at step704) and comparing the frequency components to ANSI minimumrequirements. If the shift is greater than or equal to the currentintensity level, then at step 728, the pure tone intensity moduleincrements an ambient noise repeat counter. The purpose of the counteris to ensure that any increase in the ambient noise is real and not justa temporary occurrence due to, for example, the patient coughing. Thus,the pure tone intensity module determines at step 729 whether theambient noise repeat counter is greater than a predetermined limit,meaning the increased ambient noise was detected several times. Thepredetermined limit is arbitrarily set at three in some embodiments, butmay be adjusted higher or lower as needed. In some embodiments thepredetermined limit can be set to zero so that presentations are neverrepeated. If the ambient noise repeat counter is less than thepredetermined limit, then at step 730, the pure time intensity moduleleaves the current intensity level as it is, and returns to step 702 torepeat the procedure with the intensity level unchanged. If the counteris greater than the predetermined limit, then at step 731, the pure toneintensity module increases the current intensity level by apredetermined increment, and returns to step 702 to repeat the procedurewith the new intensity level.

FIG. 8 illustrates an exemplary implementation of the pure tone initialintensity determination module, called by the pure tone intensity moduleto determine the initial testing intensity. In some embodiments, it ispossible to simply start at one end of the available intensity spectrumand gradually progress to the other end. Such a process is inefficient,however, as some intensities may be unnecessarily tested. For example,if the patient's threshold intensity for the ear and frequency beingtested is actually 20 dB, then it would be inefficient to start testingat 0 dB rather than, say, 10 dB. The pure tone initial intensitydetermination module therefore tries to choose a starting intensity thatwould eliminate at least some of the unnecessary intensities. It doesthis by identifying existing threshold intensities, if any, for the sameear, but taken from a different iteration of the module or a differentsession of hearing test. The pure tone initial intensity determinationmodule then chooses a starting intensity level based on the existingthreshold. If there are no existing thresholds, the pure tone initialintensity determination module uses an ascending intensity sweepalgorithm to determine a starting intensity.

As can be seen from the exemplary flowchart 800, the first step is todetermine whether a threshold intensity already exists for a particulartransducer (e.g., bone or air conduction), frequency and ear beingtested at step 801. The reason for this determination is some existingthresholds might need to be retested because of, for example, newinformation obtained about the opposite ear. The existing threshold maybe from a previous iteration of the module or a previous session of thehearing test provided the data is not too old (e.g., less than sixmonths). If one does exist, then the next step is to determine whetherthat existing threshold intensity is at the equipment's upper intensitylimit at step 802. If a threshold intensity is not at either the low orhigh limit of the equipment, then the pure tone initial intensitydetermination module sets the initial tests intensity equal to thethreshold intensity plus a predetermined margin at step 803. Thepredetermined margin is 5 dB in some embodiments, but may be adjustedhigher or lower as needed. The pure tone initial intensity determinationmodule thereafter concludes its procedure and returns the results to thepure tone intensity module.

If a threshold intensity does not already exist at step 801, or if theexisting threshold intensity is at the equipment's upper or lower limitat step 802, the pure tone initial intensity determination moduledetermines whether a bone threshold intensity exists for the frequencyand the ear being tested at step 804. If the determination is no, thepure tone initial intensity determination module determines at step 805whether a threshold intensity already exists for the ear being tested ata lower frequency. If the determination is again no, the pure toneintensity determination module determines at step 806 whether a bonethreshold intensity already exists for the ear being tested at a lowerfrequency. If the determination is yet again no, then the pure toneinitial intensity determination module proceeds to step 807, where ituses the sweep starting intensity as the initial sweep intensity for theascending intensity sweep algorithm. In some embodiments, the sweepstarting intensity is 20 dB, but may depend on the equipment being used.At step 808, the pure tone initial intensity determination modulepresents the pure tone frequency being tested at an intensity levelequal to the initial sweep intensity, but with a shorter duration than anormal tone presentation. A determination is made at step 809 as towhether the patient responded to the tone presented. If he did notrespond, then the intensity of the tone is increased by a predeterminedincrement at step 810, and the tone is presented again. If the patientdid respond, then at step 811, the initial intensity is set equal to theintensity of the current tone rounded down to the nearest 5 dB. Using ashorter sweep pulse with rapid increases in intensity in the absence ofpatient responses allows a very rough approximation of threshold to bequickly determined. This approximation forms the starting point for morerigorous threshold determination. The pure tone initial intensitydetermination module thereafter concludes its procedure and returns theresults to the pure tone intensity module.

If the determination made at any of steps 804, 805, and 806 is yes, thenthe pure tone initial intensity determination module proceeds to step812, where it determines whether the existing threshold is at theequipment's lower intensity limit. If it is, then the pure tone initialintensity determination module sets the initial tests intensity to 0 dBat step 813 and returns the results to the pure tone intensity module.If the existing threshold is not at the equipment's lower intensitylimit, then at step 814, a determination is made as to whether theexisting threshold is at the equipment's upper intensity limit. If itis, the pure tone initial intensity module continues to step 807 andproceeds as described above. If it is not, the pure tone initialintensity determination module sets the sweep starting intensity equalto the existing threshold minus a predetermined margin (e.g., 5 dB) atstep 815. The pure tone initial intensity determination module continuesto step 808 and proceeds as described above.

FIG. 9 illustrates a flowchart 900 for an exemplary implementation ofthe set pure tone masking levels module according to some embodiments ofthe invention. Masking prevents the non-test ear from hearing the tonepresented in the test ear due to crossover. Crossover is a phenomenon inwhich sound presented in one ear propagates through the skull andstimulates the opposite ear. This phenomenon is frequency dependent,that is, certain frequencies propagate through the skull better thanothers. The phenomenon is also transducer dependent; for example, thecrossover is different for insert earphones than for headphones at agiven frequency. Masking introduces a narrow band signal in the non-testear centered around the frequency being tested in order to “mask” thesound that has crossed over. It is important, however, to use thecorrect intensity level for the masking noise. Too little noise may beinsufficient to mask the sound, while too much noise may have a reversecrossover effect (i.e., the masking noise crosses over and is audible inthe test ear). Sometimes it is possible to arrive at the correct maskinglevel by monitoring the shift in the threshold of the test ear for eachmasking level. A linear shift, for example, may indicate the thresholdof the test ear is tracking the masking noise in the non-test ear, whichmay mean there is too much masking. This process, however, is not veryefficient. Therefore, the purpose of the set pure tone masking levelsmodule is to quickly determine approximately the right levels of maskingfor the frequency being tested.

The set pure tone masking levels module determines the appropriateamount of masking by first determining a minimum required amount ofmasking. This minimum masking level should be sufficient to overcome anyloss in the non-test ear in addition to any crossover. It should benoted that, in general, a masking level that is somewhat higher than theminimum required is acceptable, but an insufficient amount of maskingcan lead to erroneous results. If it turns out that the minimum amountof masking required for the patient is very low (i.e., below apredefined turn-on criteria), then no masking is used, as it would haveneutral or no benefit.

Otherwise, the set pure tone masking levels module sets the masking at alevel that is a little higher than the minimum required. The reason fordoing so is that a higher masking level makes it easier for the patientto distinguish the masking from a faint tone. Also, each change in themasking level may alert the patient to the tone presentation. Therefore,the set pure tone masking levels modules implements a hysteresis bysetting the masking at a level that is a little higher than the minimumrequired. This allows multiple ascending tone presentations to be madebefore having to make adjustments to the masking level.

As can be seen from the flowchart 900, the first step is to determinewhether unmasked bone is currently being tested at step 901 (see step601 in FIG. 6). If it is, then there is no need to set a masking level,and the set pure tone masking levels module concludes its procedure andreturns to the previous module. If unmasked bone is not being tested,then at step 902, the set pure tone masking levels module calculates theamount of crossover expected for the frequency being tested. In someembodiments, the crossover calculations are based on well knowninter-aural attenuation tables, an example of which is shown in Table 1below.

TABLE 1 INTER-AURAL ATTENUATION Attenuation Frequency (Hz) (dB) 250 5001000 2000 3000 4000 6000 8000 Min. 44 54 57 55 56 61 56 51 Max. 58 65 6672 72 85 76 69 Mean 51 59 61 61 68 70 65 57

Using the mean values from Table 1 above, the amount of attenuationexpected for a 500 Hz tone is about 59 dB. Thus, at this frequency, atone that has a presentation level of less than 59 dB would not produceany crossover and would not need to be masked. On the other hand, a tonethat has a presentation level of, say, 65 dB, would produce about 6 dBof crossover that would need to be masked.

Once the crossover values have been calculated for the frequency beingtested, the set pure tone masking levels module calculates at step 903the minimum required masking level and the maximum allowable maskinglevel for the frequency being tested. The minimum masking level, ingeneral, is the lowest level of masking that can still mask anycrossover in the non-test ear. In some embodiments, the minimum maskinglevel is defined as a sum of the crossover plus the non-test earair-bone gap. The crossover can be determined from the inter-auralattenuation tables as described above. The non-test ear air-bone gap, atleast initially, is assumed to be 0 dB. In some embodiments, a margin of5 dB may be added to the minimum masking level in order to ensure thereis sufficient masking, although the masking margin may be adjustedhigher or lower as needed. The maximum masking level is the level beyondwhich masking in the non-test ear will be heard in the test ear at alevel sufficient to mask the test signal being presented. In someembodiments, the maximum masking level may be defined as that levelwhich, when one subtracts the masking inter-aural attenuation, resultsin the effective presentation level. The effective presentation level isthe intensity level of the tone as it is received at the inner ear. Forair testing, the effective presentation level is the air conductionintensity level minus the air-bone gap. For bone testing, the effectivepresentation level is about equal to the bone conduction level.

At step 904, set pure tone masking levels module determines whether theminimum masking meets the masking turn-on criteria. The turn-on criteriais 0 dB in some embodiments, but may be adjusted higher as needed. Ifthe turn-on criteria is met, then at step 905, the set air tone maskinglevels module makes sure that the minimum masking is at least set to theminimum masking presentation level. The minimum masking presentationlevel is 20 dB in some embodiments, but may be adjusted higher or loweras needed. If the turn-on criteria is not met, the set pure tone maskinglevels module determines at step 906 whether the minimum masking levelis louder than the current masking level. If it is not, then the setpure tone masking levels module determines at step 907 whether theminimum masking level is much softer (e.g., about 25 dB) than thecurrent masking level. If it is again not, then the set pure tonemasking levels module makes no change to the current masking level atstep 908. Note that steps 907 and 908 are optional and are intended toact as the hysteresis function to prevent small or insignificant changesfrom being made to the masking level. In general, the fewer changes thatare made to the masking level, the better, since each change isdistracting and can potentially alert the patient that a tone is aboutto be presented.

If the minimum masking level determined in step 903 is louder than thecurrent masking level (step 906), or if the minimum masking level ismuch softer than the current masking level (step 907), then at step 909,the set pure tone masking level module sets the new masking level equalto the minimum masking level. At step 910, the set for tone maskinglevels module determines whether the new masking level is so loud as tomask the test ear. If it is, then the set pure tone masking levelsmodule sets the new masking level just below the maximum masking levelat step 911, and determines whether this new masking level provides asufficient amount of masking at step 912, that is, whether the newmasking level is greater than or equal to the minimum masking levelcalculated at step 903. If the new masking level is not loud enough,then the set pure tone masking levels module raises an indication thatthere is a masking dilemma at step 913.

On the other hand, if the new masking level is sufficiently loud, thenat step 914, the set pure tone masking levels module determines whetherthe new masking level will be louder than the equipment's loudest level.If it is, then the set pure tone masking levels module sets the newmasking level just below the equipment's limit at step 915. The set puretone masking levels module thereafter determines at step 916 whetherthis new masking level is sufficient to mask. If it is not, then at step917, the set pure tone masking levels module raises an indication thatthe resulting threshold will be undermasked. If it is, then the set puretone masking levels module determines whether the new masking level isaudible in the non-test (masked) ear at step 918. If the new maskinglevel is not audible in the non-test ear, then in some embodiments,masking is simply turned off at this point.

In some embodiments, however, the operator is given the option ofrequiring masking to be on for all bone conduction testing. If thatoption is exercised (e.g., via an internal flag), then the set pure tonemasking levels module determines at step 919 whether bone conduction iscurrently being tested, and whether masked bone conduction is required(i.e., the internal flag is set). If this determination is yes, then atstep 920, the set pure tone masking levels module sets the new maskinglevel equal to the minimum presentation level that is still audible, asdetermined by the greater of the minimum configurable masking intensity,the minimum mask turn-on level (e.g., 0 dB), and the air threshold forthe non-test ear (where available). This allows the automated hearingtest to obtain a masked bone threshold for the ear being tested eventhough the minimum calculated masking level would not have been heard bythe patient.

If bone conduction is not currently being tested, or if masking is notrequired for all bone threshold tests, then masking may be turned off atstep 921. Thereafter, the set pure tone masking levels module determineswhether masking is being attempted for the first time at step 922. If itis, then the set pure tone masking levels module warns the patient thatmasking is about to begin at step 923. If it is not, as in the case whenmasking is turned off, the set pure tone masking levels module concludesits procedure and returns the results to the pure tone intensity module.In some embodiments, after step 921, the set pure tone masking levelsmodule may proceed directly to the conclusion of the procedures.

FIG. 10 illustrates a flowchart 1000 for an exemplary implementation ofthe threshold detection module according to some embodiments of thepresent invention. This module is the one called by the pure toneintensity module (FIG. 7) to determine whether a threshold intensity hasbeen reached. The threshold detection module makes this determination bycomparing the current intensity to a number of predetermined milestonesor indicators. Depending on the comparisons, the threshold detectionmodule records the threshold, if any, as a Type 1, 2, or 3 categorythreshold. These threshold types are arbitrarily assigned to indicatethere are different ways that a threshold may be detected. In general,certain approaches to threshold determination may be optimal for speechthresholds, while other approaches are optimal for pure tone thresholds.The threshold detection module accommodates the different approaches byimplementing more than one way to establish a threshold. Although onlythree threshold types are discussed, other threshold detectiontechniques may certainly be added to the threshold detection module asneeded. Another key design feature of the threshold detection module isthat it checks to make sure that the threshold reached was notsignificantly affected by any ambient noise that may have been present.

The first step that is performed by the threshold detection module is todetermine whether the patient failed to respond at the equipment's upperintensity limit at step 1001. If he did, then the threshold detectionmodule notes that the patient's threshold intensity for the frequencybeing tested is beyond the limit of the equipment at step 1002, andthereafter concludes its procedure. If the patient did respond at orbelow the equipment's upper intensity limit, then at step 1003, thethreshold detection module proceeds to calculate several milestones orindicators, including: (T) total number of responses at intensitieswithin 15 dB of the current intensity, (R) number of responses at thecurrent intensity, (NR) number of non-responses at the currentintensity, (NL) number of responses that are unaffected by ambient noiseat the next lower intensity, (V) the number of reversals in thedirection of progression of the intensity presentations, and (M) theaverage of the intensity values where reversals have occurred, excludingthe first two values in some embodiments. It should be emphasized thatthese particular milestones or indicators are exemplary only, and thatother milestones or indicators may also be used without departing fromthe scope of the invention.

After the milestones or indicators have been calculated, the thresholddetection module in one embodiment proceeds to step 1004, where itdetermines whether the current threshold detection is for speechreception threshold (i.e., the module was called by the speech receptionthreshold module). If it is not, the threshold detection moduledetermines whether the current threshold detection is the firstthreshold detection at step 1005. If it is the first thresholddetection, then one embodiment of the threshold detection moduleincreases the minimum response count to allow for training purposes atstep 1006. For example, usually the minimum response count may be setequal to two, but may be equal to three or more for the first thresholddetection to allow the patient to become familiar with the procedure.

If the current threshold detection is not the first threshold detection,the threshold detection module proceeds directly to step 1007 todetermine whether the current intensity level is greater than theprevious intensity level, i.e., greater than the intensity level usedthe last time the threshold detection module was called. If it isgreater, then at step 1008, the threshold detection module determineswhether the number of responses at the current intensity level exceedsthe minimum response count. If it does exceed the minimum responsecount, then at step 1009, the threshold detection module determineswhether the number of responses at the current intensity level (R) isgreater than the number of non-responses at this intensity level (NR).If (R) is not greater than (NR), then at step 1010, the thresholddetection module determines whether the ratio of the number of responsesat the current intensity level (R) over the total number of responses atintensities within 15 dB of this intensity (T) is greater than theminimum response ratio. In some embodiments, the minimum response ratiois set to one-half, but may be adjusted higher or lower as needed. Theratio (R)/(T) can indicate whether the responses are being clustered orgrouped together around a certain intensity level, which may indicatethe patient has a threshold at that intensity level.

If (R)/(T) is greater than the minimum response ratio in step 1010, thenthe threshold detection module indicates that a threshold has beenreached, and assigns it a Type 2 for internal usage at step 1011. Thethreshold detection module thereafter determines at step 1012 whetherthe number of non-responses that are unaffected by ambient noise at thenext lower intensity level is greater than or equal to a minimum value.The minimum value may be one in some embodiments, but may be adjustedhigher as needed. If (NL) is greater than or equal to the minimum value,then ambient noise was not a significant factor in the thresholddetection, and the threshold detection module concludes its procedureand returns to the pure tone intensity module. Otherwise, if (NL) isless than the minimum value, then at step 1013, the threshold detectionmodule marks the resulting threshold as possibly shifted by ambientnoise.

If, on the other hand, (R) is greater than (NR) at step 1009, thethreshold detection module indicates that a threshold has been reachedat step 1014, and assigns it a Type 1 for internal use. The thresholddetection module then proceeds to step 1012 for the affected by ambientnoise check.

Furthermore, if the current intensity level is not greater than theprevious intensity level (step 1007), or (R) is not greater than theminimum response counter (1008), or (R)/(T) is not greater than theminimum response ratio (step 1010), then there is no threshold detected,and the threshold detection module simply concludes its procedure.

If it turns out that the current threshold detection is for a speechthreshold (step 1004), then at step 1015, the threshold detection moduledetermines whether the patient responded correctly at the equipment'slower intensity limit. If he did, then at step 1016, the thresholddetection module notes that the patient's threshold intensity is belowthe equipment's lower intensity limit. If the patient did not respondcorrectly at the lower intensity limit, then at step 1017, the thresholddetection module determines whether the number of reversals (V) isgreater than or equal to a reversal limit. In some embodiments, thereversal limit is four, but may be adjusted higher or lower as needed.If (V) is not greater than or equal to the reversal limit, then thecurrent intensity is not a threshold, and the threshold detection moduleconcludes its procedure. Otherwise, the threshold detection module notesthat a threshold has been reached at an intensity level equal to theaverage of the intensity values where reversals have occurred (M) atstep 1018, and assigns it a Type 3 for internal use. The thresholddetection module then proceeds to step 1012 for the affected by ambientnoise check.

FIG. 11 illustrates a flowchart 1100 for an exemplary implementation ofthe speech reception threshold module according to some embodiments ofthe invention. The speech reception threshold module is called by themain program module to perform the speech reception threshold test. Insome embodiments, the speech reception threshold module calculates abest performance intensity level and an expected performance intensitylevel according to a performance intensity (PI) curve. The PI curve is aprediction of the patient's performance at various intensity levelsbased on an Articulation Index (AI). The AI is a mathematical formulathat is used to predict the word recognition ability of normal listenersgiven any combination of test material, frequency filter, level, andnoise. For more information about the AI and the PI curve, see “Thearticulation index in clinical diagnosis and hearing aid fitting,” byChris Halpin, PhD, Aaron Thornton, PhD, and Zezhang Hous, PhD, CurrentOpinion in Otolaryngology & Head and Neck Surgery, 4:325-334, 1996.

The speech reception threshold module then uses the best performanceintensity level and the expected performance intensity level to controlthe intensity levels of the speech reception threshold test. Such anarrangement helps avoid having to start the speech reception thresholdtest at an intensity level that is too low or too high. If there is noexisting data on the patient from which to calculate these intensitypoints, then the speech reception module starts with a fairly loudvolume, for example, 60 dB, then quickly steps the intensity down untilthe patient can no longer hear the presentations. After that, theintensity levels are adjusted in smaller increments. If data exists, thespeech reception threshold module sets the starting intensity leveldirectly to the expected performance intensity level and increases ordecreases it in small increments to reach a threshold intensity.

The speech reception threshold module then presents a set of randomlychosen pictures to the patient along with the words for the pictures. Insome embodiments, the same set of randomly chosen pictures is used forthe entire test, although it is possible to use more than one set.Preferably, the words that are used are compound words with two distinctsyllables. For languages where no such words are used, appropriatesubstitutes may be made. The words are randomly presented one at a timeto the patient with no emphasis on any syllable. The speech receptionthreshold module then waits for the patient to select the picturematching the word presented. For the first intensity level, a singleresponse, whether correct or incorrect, initiates the thresholddetection procedure. For each subsequent intensity level, two or moreresponses are needed, whether correct or incorrect, before thresholddetection is initiated. In some embodiments, two consecutive wrongchoices result in an incorrect answer, and two consecutive right choicesresult in a correct answer. Where there is one wrong choice followed byone right choice, the next choice determines whether the answer iscorrect or incorrect.

Referring now to FIG. 11, at the first step 1101, the speech receptionthreshold module determines whether all of the pure tone thresholds areat the upper limit of the equipment. If they are, then that means theear being tested is not capable of hearing any tones (i.e., the ear is adead ear). At this point, the speech reception threshold module simplynotes that the ear could not be tested at step 1102. The speechreception threshold module thereafter concludes its procedure andreturns to the calling module.

If the ear is not a dead ear, then at step 1103, the speech receptionthreshold module determines whether there is a masking dilemma at any ofthe pure tone average (PTA) frequencies of 500 Hz, 1000 Hz and 2000 Hz.If there is a masking dilemma, then the speech reception thresholdmodule again notes that the ear could not be tested at step 1102. If,however, there is no masking dilemma, then at step 1104, the speechreception threshold module calculates the best and expected performanceintensity levels. The best performance intensity level (PBTest) is thehighest point on the PI curve and is the intensity level where thepatient should get the most correct responses to word presentations. The50 percent performance intensity level (PredictedSRT) is the middlepoint of the PI curve and is the point where the patient shouldcorrectly respond to about half of all presentations.

After PBTest and PredictedSRT have been calculated, the speech receptionthreshold module randomly chooses a set of word-picture pairs at step1105. Nine word-picture pairs are used in the exemplary embodiment, butfewer or more word picture pairs may be used. Preferably, there areenough pictures to limit the possibility of correct guessing while atthe same time make identifying the correct picture a simple task. Insome embodiments, a method of indicating none of the above or word notunderstood may be provided, either in addition to or in place of one ofthe pictures. In the English language, the words chosen are known as“spondees” and usually have two distinctive sounding syllables utteredwith equal accent on each syllable. In other languages, the words mayhave more than two syllables. At step 1106, the speech receptionthreshold module presents the set of pictures on the display screen. Atstep 1107, the speech reception threshold module sets the startingintensity equal to PredictedSRT. In some embodiments, the speechreception threshold module also adds a small training margin, but doesnot set the starting intensity to be louder than PBTest.

At step 1108, the speech reception threshold module sets the trial sizeequal to one for the initial intensity decrease. The speech receptionthreshold module thereafter initializes a count of correct responses andcount of incorrect responses to zero at step 1109. Next, the speechreception threshold module checks to see if the word queue is empty atstep 1110. If it is, the speech reception threshold module fills theword queue at step 1111 with non-repeating words corresponding to thepictures that are displayed. In some embodiments, the word queuecontains four words randomly selected from the set of available words,but larger or smaller word queue sizes can be used. The speech receptionthreshold module thereafter chooses and removes one of the words fromthe queue at step 1112, and sets the speech masking level module at step1113. The speech reception threshold module sets the speech maskinglevel by calling the set speech masking level module (described below)and passing the appropriate information thereto. Once masking isinitiated, the speech reception threshold module presents the word atthe current intensity at step 1114, and waits for a predefined period oftime for the patient to respond at step 1115. The waiting period in someembodiments is 3 seconds, but may be longer or shorter.

At step 1116, a determination is made as to whether the patientresponded. If he did not respond, then at step 1117, the speechreception threshold module raises a no picture was chosen warning to thepatient, and returns to step 1115 to await the patient's response. Thiswarning may take the form of an on-screen message, a verbal indicationpresented via the insert earphones, or both. In some embodiments, theoperator is paged if the patient repeatedly fails to respond in order towake the patient if needed or otherwise to help him complete the pictureselection task. If the patient did respond, then at step 1118, thespeech reception threshold module determines whether the patient pickedthe correct picture. If the patient picked the wrong picture, the speechreception threshold module increments the wrong-count counter at step1119. Otherwise, the speech reception threshold module increments thecorrect-count counter at step 1120. Thereafter a determination is madeat step 1121 to determine if the wrong-count counter is greater than aminimum count. In some embodiments, the minimum count is the trial sizedivided by two. Note that for the starting intensity, since the trialsize is initially one, any response will push either the wrong-countcounter or the correct-count counter over the minimum count. If thewrong-count counter is not greater than the minimum count, then thespeech reception threshold module determines at step 1122 whether thecorrect-count counter is greater than a minimum count. If thecorrect-count counter is also not greater than the minimum count, thenno score is given at step 1123, and the speech reception thresholdmodule returns to step 1110 to present the next word from the queue.

On the other hand, if the correct-count counter is greater than theminimum count, then at step 1124 the speech reception threshold modulescores the response as speech correctly heard. Similarly, if thewrong-count counter is greater than the minimum count, then at step1125, the speech reception threshold module scores the response asspeech not correctly heard. At step 1126, the speech reception thresholdmodule resets the trial size equal to the speech threshold trial size.In some embodiments, the speech threshold trial size is three, but maybe adjusted higher as needed. At step 1127, the speech receptionthreshold module sets the descending intensity interval equal to theascending intensity interval. In some embodiments, the initialdescending intensity interval is set to 10 dB and the initial ascendinginterval is set to 5 dB.

Thereafter, the speech reception threshold module determines whether thecurrent intensity is a threshold intensity at step 1128, by calling thethreshold detection module (see FIG. 10). A determination is then madeat step 1129 as to whether a threshold intensity was detected by thethreshold detection module. If a threshold was indeed detected, then thespeech reception threshold module concludes its procedure and returnsthe results to the main program module. If a threshold was not detected,then at step 1130, the speech reception threshold module determineswhether the response was scored as speech correctly heard. If theresponse was scored a speech not correctly heard, then at step 1131, thespeech reception threshold module increases the intensity by an amountequal to the ascending interval. Otherwise, if the response was scoredas speech correctly heard, then the speech reception threshold moduledecreases the intensity by an amount equal to the descending interval atstep 1132. Thereafter, the speech reception module returns to step 1109to present the next word.

Note that in the foregoing embodiments the trial size is set to one atthe start and subsequently increased. The beginning trial size is set atone so that, initially, every picture choice is scored as either heardor not heard. This lets the output level quickly descend from itsstarting level to a level approximately where the threshold will be.Once the patient misses a word, the trial size is increased in order toensure that a legitimate response is received. For example, by requiringtwo out of three picture choices to ascertain whether the patient hearsat the current level, the chance of the patient making a lucky guess isreduced (e.g., from 1/9 to 2/81).

FIG. 12 illustrates a flowchart 1200 for an exemplary implementation ofthe set speech masking levels module according to some embodiments ofthe invention. The set speech masking levels module is called by thespeech reception threshold module to determine an appropriate maskinglevel for the non-test ear. In this regard, the set speech maskinglevels module has some similarities to the set pure tone masking levelsmodule (see FIG. 9) described previously. For example, the set speechmasking levels module uses a minimum masking level and a maximum maskinglevel to control selection of the masking noise intensity. Such anarrangement helps avoid having to start selection of the masking noiseintensity at a level that is too low or too high. The set speech maskinglevels module also implements a hysteresis in order to avoid makingsmall, incremental changes to the masking level.

As can be seen in step 1201, the set speech masking levels modulecalculates a minimum masking level and a maximum masking level from theArticulation Index. In some embodiments, the minimum masking level maybe defined as the level of masking noise that makes any speech crossingover to the non-test ear unintelligible. If desired, a masking marginmay be added (e.g., 5 dB) to ensure that the minimum masking level willnot be too low. The maximum masking level, on the other hand, may bedefined as the level of masking noise beyond which, if one subtractedthe masking interaural attenuation, will have the undesirable effect ofmasking the speech presented in the test ear.

Once these minimum and maximum masking noise intensity levels have beencalculated, then at step 1202, the set speech masking levels moduledetermines whether the minimum masking level is louder than the currentmasking level (e.g., from a previous iteration of the set speech maskinglevels module). If it is, then the set speech masking levels module setsthe new masking level equal to the minimum masking level at step 1203.Otherwise, the set speech masking levels module determines at step 1204whether the minimum masking level is much softer (e.g., more than 25 dBsofter) then the current masking level. If the minimum masking level ismuch softer, then the new masking level is set to the minimum maskinglevel (step 1203). On the other hand, if the minimum masking level isnot much softer than the current masking level, then no change is madeto the current masking level at step 1205. Note that steps 1204 and 1205are optional steps that serve as a hysteresis to prevent small or minorchanges in the masking level from being made.

At step 1206, the set speech masking levels module determines whetherthis new masking level is so loud as to cross over and mask the testear. If it is, then at step 1207, the set speech masking levels modulesets the new masking level just below the maximum masking levelcalculated above. Otherwise, at step 1208, the set speech masking levelsmodule determines whether the new masking level will be louder than theequipment's upper intensity limit. If so, then at step 1209, the setspeech masking levels module sets the new masking level to just belowthe upper limit of the equipment. If not, at step 1210, the set speechmasking levels module determines whether the new masking level providesa sufficient level of masking noise, that is, a level equal to orgreater then the previously calculated minimum masking level. If the newmasking level provides an insufficient level of masking, then the setspeech masking levels module reports the new masking level as resultingin a masking dilemma, and concludes its procedure. Otherwise, the setspeech masking levels module determines at step 1212 whether the newmasking level meets the masking turn-on criteria (typically, 0 dB). Ifit does not, then masking is turned off at step 1213, and the set speechmasking levels module thereafter concludes its procedure. Otherwise, theset speech masking levels module simply concludes its procedure (i.e.,without turning masking off).

FIG. 13 illustrates a flowchart 1300 for an exemplary implementation ofthe speech discrimination module according to some embodiments of theinvention. The speech discrimination module is called by the mainprogram module to perform speech discrimination testing. Unlike the puretone threshold module or the speech reception threshold module, thespeech discrimination module does not test the patient's thresholdintensity. Rather, the speech discrimination module uses an intensitylevel that is most likely to result in the patient being able to hearthe speech. The speech discrimination module thereafter determines howwell the patient is able to discern between similar sounding words.

The words are preferably single syllable words that sound alike. Forlanguages where such words are not available, appropriate adjustmentsmay be made. A group of pictures is presented for each word. In someembodiments, the same pictures are used for each word. It is possiblethat some pictures will overlap from word to word, but there should norepeats of entire picture sets. The speech discrimination modulerandomly chooses the groups of pictures from a large pool of suchpicture groups, then presents the words at a constant level, one at atime, with each group of pictures. The speech discrimination modulethereafter waits for the patient to respond.

The speech discrimination module concludes it procedure when either asufficient percentage of correct responses has been received (e.g., 85percent), or a large enough sample has been obtained to give an accurateassessment. In some embodiments, the percentage of correct responses isevaluated on a word by word basis, with a predetermined minimum of, forexample, 10 correct words. Thus, if the patient responds correctly forthe first 10 words, there is no need to continue testing, and the speechdiscrimination module may conclude its procedure by issuing a score of100 percent speech discrimination accuracy. Similarly, if after 50words, the patient has only chosen 20 of the correct pictures, thenagain there is probably no need to continue testing. In the latter case,the speech discrimination module issues a score reflecting theappropriate speech discrimination accuracy percentage (e.g., 60 percentdiscrimination loss). If, on the other hand, after 15 words the patienthas only given 12 correct answers, then the speech discrimination modulecontinues with testing until the termination conditions have been met.

In the first step 1301, the speech discrimination module determineswhether all of the pure tone thresholds are at the upper limit of theequipment. If they are, then that means the ear being tested is notcapable of hearing any tones, i.e., the ear is a dead ear. At thispoint, the speech discrimination module simply notes that the ear couldnot be tested at step 1302. The speech discrimination module thereafterconcludes its procedure and returns to the calling module.

If the ear is not a dead ear, then at step 1303, the speech receptionthreshold module determines whether there is a masking dilemma at any ofthe PTA frequencies. If there is a masking dilemma, then the speechdiscrimination module again notes that the ear could not be tested atstep 1302. If there is no masking dilemma, then at step 1304, the speechdiscrimination module calculates PBTest for the patient. Recall thatPBTest is the close to the highest point on the PI curve and is theintensity level where the patient should have the best chance tocorrectly respond to presentations. If there is no data from which tocalculate PBTest, then the speech discrimination module sets theintensity level to a fairly loud volume, for example, 60 dB.Alternatively, the speech discrimination module may use an average ofthe pure tone intensities (if available) plus some predetermined margin(e.g., 40 dB). In other embodiments, it is also possible to let thepatient adjust the intensity to a volume that he's comfortable with.

After PBTest has been calculated, the speech discrimination modulerandomizes and queues several groups of word-picture pairs at step 1305.In some embodiments, there are four word-picture pairs per group, and atotal of about 100 groups, although these numbers may be adjusted higheror lower as needed. The four word-picture pairs within a group areselected such that the words sound similar to each other. At step 1306,the speech discrimination module sets the intensity level of thepresentation equal to PBTest. At step 1307, the speech discriminationmodule sets the masking level so that each ear can be tested, forexample, by calling the set speech masking levels module (FIG. 12). Atstep 1308, the speech discrimination module clears three separatecounters: a correct-count counter, a wrong-count counter, and atotal-count counter.

At step 1309, the speech discrimination module displays the fourpictures in the group of word-picture pairs that is up next in thequeue. The speech discrimination module thereafter presents one of thewords from the group of four word-picture pairs at step 1310, and waitsfor the patient to respond at step 1311. At step 1312, the speechdiscrimination module determines whether the patient has responded. Ifthere is no response, the speech discrimination module issues a nopicture chosen warning to the patient at step 1313 and returns to step1311 to await the patient's response. Otherwise, the speechdiscrimination module proceeds to step 1314 where it increments thetotal-count counter. A determination is made at step 1315 as to whetherthe patient chose the correct picture. If the patient chose the correctpicture, then at step 1316, the correct-count counter is incremented. Ifthe patient did not choose the correct picture, then at step 1317, thewrong-count counter is incremented.

Thereafter, at step 1318, the speech discrimination module determineswhether the total-count is greater than a predetermined minimum, forexample, 12 words. If the total-count is less than or equal to thepredetermined minimum, then the speech discrimination module returns tostep 1309, where it presents the next group of four pictures in thequeue. If the total-count is greater than the predetermined minimum,then at step 1319, the speech discrimination module determines whetherthe total-count is greater than a predetermined maximum, for example,100 words. If it is, then the speech discrimination module proceeds tostep 1320, where it corrects the final score to compensate for anyguessing. In some embodiments, the speech discrimination modulecompensates for guessing by determining the following: p the number ofpictures displayed for each word (nominally 4); n the number of wordspresented; s the number of words actually correctly heard by thepatient; g the number of words not correctly heard by the patient butguessed correctly; and c the number of correct picture choices made bythe patient whether heard or not heard, e.g. the correct-count counterdescribed above. By these definitions, c=s+g. Furthermore, the expectedvalue of g is (n−s)/p, as it represents the score one would get byguessing each of the (n−s) unheard words from p pictures. Solving for syields: s=(pc−n)/(p−1).

On the other hand, if the total-count is less than or equal to thepredetermined maximum, then the speech discrimination module proceeds tostep 1321, where it calculates an error range and termination conditionsfrom the correct-count and wrong-count. At step 1322, the speechdiscrimination module determines whether the termination conditions havebeen met. If they have not, then the speech discrimination modulereturns to step 1309, where it presents the next set of four pictures inthe queue. If the termination conditions have been met, then the speechdiscrimination module proceeds to step 1320, where it corrects the finalscore to reflect any guessing and concludes the procedure.

FIG. 14 illustrates a flowchart 1400 for an exemplary implementation ofthe patient management module according to some embodiments of theinvention. The patient management module is called by other modules tokeep the patient on track and the testing running smoothly. Thus, if thepatient is not responding, or is responding too quickly, the patientmanagement module may issue a warning to the patient. If the patient'sresponses indicate that there is an equipment problem, the patientmanagement module may alert the operator. Alerting the operator may beaccomplished by wireless paging or by any other suitable techniques(e.g., e-mail, console lights, buzzer, etc.).

As can be seen in FIG. 14, the first step in the flowchart 1400 is thepatient management module receives an indication of a problem from acalling module at step 1401. The patient management module thereafterdetermines at step 1402 whether the problem is a patient warning event.If it is, then the patient management module issues warning to thepatient at step 1403. In some embodiments, the patient management modulereferences a table that specifies which types of events are patientwarning events and also the particular warning message to be issued tothe patient. Such patient warning events include, for example, eventsthat trigger the warnings in steps 713, 715, 726, 923, 1117, and 1313,described above. The warning messages may also include short textmessages describing the problem to the patient. The warnings may includean onscreen acknowledgment such as an “OK” button or a “Continue”button. The patient must then acknowledge the warning in order tocontinue.

In some embodiments, the patient management module determines whetherthe particular patient warning has been issued a predetermined number oftimes at step 1404. This may indicate that the patient is having thesame difficulty over and over again. If it has, then the patientmanagement module may page the operator at step 1406. In someembodiments, the patient management module may also page the operator ifthe patient has not acknowledged the warning message within apredetermined amount of time.

Otherwise, the patient management module determines whether the problemis an operator paging event at step 1405. If it is, then the patientmanagement module pages the operator at step 1406. As before, thepatient management module may reference a table that specifies whichtypes of events are operator paging events and the messages to be issuedto the operator. In some embodiments, the messages may be in the form ofcode words that represent different types of problems. Examples ofevents that are operator paging events include step 610 (e.g., thetransducer is probably mounted incorrectly) and any other indication ofequipment problems. Operator paging may also occur if the hearings testis not completed within a given amount of time, or if the patientrequests help.

At step 1407, the patient management module performs additionalprocessing, such as compiling the number and types of warnings that weretriggered for the patient. This information may then be used to adjustthe hearing test for the patient as needed, either within the currenttest session, or in future test sessions for this patient. For example,if the patient is routinely slow in responding during the pure tonefrequency threshold test, the allotted amount of time for answering maybe increased for the other tests during this session, or for futuresessions.

To demonstrate the accuracy of the automated hearing test, severalstudies were recently conducted. In one representative study, a group of15 patients were tested using the traditional, manually administeredhearing test and also using the automated hearing test of the presentinvention. The results are summarized in Table 2 below. Briefly, 96percent of all thresholds tested with the automated hearing test of thepresent invention were within 10 dB of the manually administered test.Likewise, 98 percent of all air thresholds, 91 percent of all bonethresholds, and 93 percent of all speech reception thresholds werewithin 10 dB of the manually administered test. As for speechdiscrimination, the average difference between the automated hearingtest of the present invention and the manually administered test was 0.8percent. Thus, in addition to being easier, more convenient, and lessexpensive, studies have shown that the automated hearing test of thepresent invention is substantially as accurate as the traditional,manually administered test.

TABLE 2 Results of Automated Hearing Test Pure Tone and SRT ResultsTotal Air Bone SRT Thresholds measured 255 180 45 30 0 dB difference tomanual (%) 45 50 29 40 0-5 dB difference to manual (%) 85 91 69 70 0-10dB difference to manual (%) 96 98 91 93 0-15 dB difference to manual (%)99 99 98 100 Over 15 dB difference to manual 1 1 2 0 (%)

While the invention has been described with respect to a number ofspecific embodiments, those skilled in the art will recognize that theinnovative concepts described herein can be modified and varied over awide range of applications. Accordingly, the scope of the inventionshould not be limited to any of the specific exemplary teachingsdiscussed, but is instead defined by the following claims.

1. A computer-based, multimedia method for quickly and convenientlytesting a patient's hearing without a sound isolation chamber and withminimal assistance from an operator, comprising: presenting to thepatient a list of available hearing tests, including a pure tone test, aspeech reception test, and a speech discrimination test; prompting thepatient to select one or more hearing tests from the list of availablehearing tests; and performing each hearing test selected by the patient,wherein test data obtained during one hearing test is used in anotherhearing test, and test data obtained during one iteration of a hearingtest is used in subsequent iterations of that hearing test; and whereinthe pure tone test is one of one or more hearing tests selected by thepatient and is performed by obtaining a hearing threshold for aplurality of predetermined frequencies and obtaining an unmasked boneconduction hearing threshold for one or more of the predeterminedfrequencies.
 2. The method according to claim 1, further comprisingprompting the patient to select from a list of available languages to beused for the hearing tests.
 3. The method according to claim 1, whereinthe list of available hearing tests includes a tympanogram test,acoustic reflex test, and otoacoustic emissions test, further comprisingacquiring tympanogram or acoustic reflex data for each ear of thepatient if the tympanogram or acoustic reflex test is selected.
 4. Themethod according to claim 1, further comprising paging the operator uponcompletion of the selected hearing tests.
 5. The method according toclaim 1, wherein the step of obtaining a hearing threshold furthercomprises issuing a bone conduction threshold warning if an airconduction hearing threshold for a first ear is larger than the unmaskedbone conduction threshold by a predetermined amount.
 6. The methodaccording to claim 1, wherein the predetermined frequencies are between250 Hz and 8000 Hz.
 7. The method according to claim 6, wherein the puretone test is further performed by skipping the hearing threshold forcertain frequencies if the hearing threshold for other frequencies meetpredefined criteria.
 8. The method according to claim 6, wherein thestep of obtaining a hearing threshold further comprises, for eachfrequency being tested, determining a better ear and a poorer ear basedon the unmasked bone conduction threshold.
 9. The method according toclaim 8, wherein the step of obtaining a hearing threshold furthercomprises, for each frequency being tested, determining one or morehearing thresholds, including at least an air conduction hearingthreshold for the better ear and the poorer ear.
 10. The methodaccording to claim 9, wherein the step of obtaining a hearing thresholdfurther comprises, for the first frequency being tested, issuing a boneconduction threshold warning if the air conduction hearing threshold forthe better ear is larger than the unmasked bone conduction threshold bya predetermined amount.
 11. The method according to claim 9, wherein thestep of obtaining a hearing threshold further comprises, for eachfrequency being tested, determining a masked bone hearing threshold forthe poorer ear if an air-bone gap for either ear is larger than apredetermined amount.
 12. The method according to claim 11, wherein thestep of obtaining a hearing threshold further comprises, for eachfrequency being tested, determining a masked bone hearing threshold forthe better ear if a masked bone-unmasked bone gap for the poor ear issmaller than a predetermined amount.
 13. The method according to claim12, wherein the step of obtaining a hearing threshold further comprises,for each ear and frequency being tested, evaluating whether maskinglevels used for all hearing thresholds were correct, and correcting themasking levels as needed based on available hearing thresholds.
 14. Themethod according to claim 9, wherein the step of determining one or morehearing thresholds includes estimating an initial intensity level to beused for each ear and frequency being tested.
 15. The method accordingto claim 14, wherein the step of estimating an initial intensity levelincludes presenting a tone to the patient at a predetermined startingintensity and increasing the intensity of the tone by a predeterminedincrement until the patient responds.
 16. The method according to claim14, wherein the step of determining one or more hearing thresholdsincludes, for each ear and frequency being tested, estimating a maskinglevel to be used and terminating the determination if the estimatedmasking level results in a masking dilemma.
 17. The method according toclaim 16, wherein the step of determining one or more hearing thresholdsincludes, for each ear and frequency being tested, introducing a randomdelay before presenting a tone to the patient if the estimated maskingresults in a masking level change.
 18. The method according to claim 16,wherein the step of determining one or more hearing thresholds includes,for each ear and frequency being tested, introducing a random delaybefore presenting a tone to the patient if the patient made any previousresponses.
 19. The method according to claim 16, wherein the step ofdetermining one or more hearing thresholds includes, for each ear andfrequency being tested, presenting a tone with a frequency substantiallyequal to the frequency being tested and waiting for the patient torespond.
 20. The method according to claim 19, wherein the step ofdetermining one or more hearing thresholds includes, for each ear andfrequency being tested, issuing a false response warning to the patientif the response is received before the tone presentation and masking isbeing used for the first time.
 21. The method according to claim 19,wherein the step of determining one or more hearing thresholds includesmeasuring an ambient noise and determining an ambient noise indicator.22. The method according to claim 21, wherein the ambient noiseindicator is an ambient noise threshold shift, and the ambient noisethreshold shift must be greater than the current intensity of the tonefor a predetermined number of iterations before intensity of the tone isincreased.
 23. The method according to claim 19, wherein the step ofdetermining one or more hearing thresholds includes, for each ear andfrequency being tested, checking whether a hearing threshold is reachedupon receiving the response within an acceptable time.
 24. The methodaccording to claim 23, wherein the step of checking whether a hearingthreshold has been reached includes, for the intensity being used,marking the hearing threshold as an overlimit threshold if the patientfails to respond to an intensity near an equipment upper intensitylimit.
 25. The method according to claim 24, wherein the step ofchecking whether a hearing threshold has been reached further includes,for the intensity being used, calculating a plurality of thresholdindicators, including: a total number of responses at intensities withina predetermined amount of the intensity being used; a number ofresponses at the intensity being used; a number of non-responses at theintensity being used; a number of non-responses at a lower intensitylevel that were unaffected by ambient noise; a number of reversals inintensity presentation; and an average of intensity levels wherereversals occurred.
 26. The method according to claim 25, wherein ahearing threshold has been reached if the number of responses at theintensity being used is greater than the number of non-responses at theintensity being used, provided the number of responses at the intensitybeing used is greater than a predetermined minimum response and theintensity being used is greater than a previous intensity used.
 27. Themethod according to claim 26, wherein the step of checking whether ahearing threshold has been reached further includes increasing thepredetermined minimum response to allow for training.
 28. Acomputer-based, multimedia method for quickly and conveniently testing apatient's hearing without a sound isolation chamber and with minimalassistance from an operator, comprising: presenting to the patient or anoperator a list of available hearing tests, including a pure tone testand a speech reception test; and forming each hearing test on thepatient, wherein test data obtained during one hearing test is used inanother hearing test and test data obtained during one iteration of ahearing test is used in subsequent iterations of that hearing test; andwherein the pure tone test is performed by obtaining a hearing thresholdfor a plurality of predetermined frequencies and obtaining an unmaskedbone conduction hearing threshold for one or more of the predeterminedfrequencies.
 29. The method according to claim 28, wherein the step ofobtaining a hearing threshold further comprises issuing a boneconduction threshold warning if an air conduction hearing threshold fora first ear is larger than the unmasked bone conduction threshold by apredetermined amount.
 30. A computer-based, multimedia method forquickly and conveniently testing a patient's hearing without a soundisolation chamber and with minimal assistance from an operator,comprising: presenting to the patient or an operator a list of availablehearing tests, including a pure tone test, a speech reception test, anda speech discrimination test; and performing each hearing test on thepatient, wherein test data obtained during one hearing test is used inanother hearing test; and wherein the pure tone test is performed byobtaining a hearing threshold for a plurality of predeterminedfrequencies and obtaining an unmasked bone conduction hearing thresholdfor one or more of the predetermined frequencies.
 31. The methodaccording to claim 30, wherein the step of obtaining a hearing thresholdfurther comprises issuing a bone conduction threshold warning if an airconduction hearing threshold for a first ear is larger than the unmaskedbone conduction threshold by a predetermined amount.